Please provide the following contact information:

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State
Zip Code
Country
Work Phone
Home Phone
E-mail

What is the brand name of the computer you want to cover?

Enter the serial number of your computer (if known):

Choose which plan you prefer:

Pull down menu to choose 1 year plan 2 year plan 3 year plan

Type of computer:

PC
Laptop

By submitting this form, I authorize Town Computer to charge my credit card the exact amount for the product that I purchased.

Please provide the following payment information:

	BILLING
Credit Card	Pull down to choose VISA MasterCard
Cardholder Name
Card Number
Expiration Date

	Billing Address
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

If you understand and agree with the terms of the Assurance Plan Agreement, click "I Agree" to submit form. Once you submit the form the order will be processed.  There is no return on the Assurance Plan.